WASHINGTON—Imagine two soldiers: both experienced the exact same traumatic event while serving in theater. Both arrive home and are diagnosed with post-traumatic stress disorder that has been linked by a physician to that event. However, while one’s claim is easily accepted by the Department of Veterans Affairs, the other has to struggle to prove his condition is service-connected.

That is the scenario legislators are being asked to take into account as they consider redefining combat in the context of proving service-connection for VAbenefits.

“What does it mean to have been ‘engaged in combat with the enemy’ to a sufficient enough degree to prove a stressor that in turn warrants service connection for post-traumatic stress disorder?” asked Rep. John Hall, D.-N.Y., chairman of the House VA subcommittee on disability assistance and memorial affairs at a hearing last month. “The current Rating Schedule for PTSD has been described as vague and subjective. Furthermore, the adjudication process does not solely accept, as the law prescribes, lay evidence as sufficient proof as long as it is consistent with the circumstances, conditions, or hardships of such service, notwithstanding that there is no official record.”

The current law predicates service-connection on engagement “in combat with the enemy,” a phrase that Rep. Hall believes is too vague, and does not adequately address the changes that have occurred in modern warfare. “Warfare encompasses acts of terrorism, insurgency, and guerilla tactics. No place is safe and the enemy may not be readily identifiable,” Rep. Hall declared.

PTSD, Rep. Hall explained, is a condition that is further exacerbated by stress, and the House VA committee has heard numerous veterans testify over the last several years of how the stress of dealing with the red tape at VA in an attempt to improve their situation only made their problems worse.

“There should be a better way for VA to assist veterans who are suffering from PTSD adjudicate those claims without it being burdensome, stressful and adversarial,” Rep. Hall said.

The Parable of the Two Soldiers

The “two veterans” scenario was put before the legislators by Ian C. De Planque, assistant director of the veterans affairs and rehabilitation commission of the American Legion who argued that the statutes originally created in 1941 did not conceive of what being in a combat zone means in the age of modern warfare.

“Imagine a convoy travelling through Southeastern Afghanistan,” De Planque said. “An IED detonates ahead of them on the road. Fortunately no American soldiers are injured and no vehicles are damaged in the blast. However, by the side of the road, a family of Afghans on the side of the road are killed instantly.”

Two soldiers witnessed the event: one is an infantrymen and recipient of the combat infantrymen badge, the other a mechanic pulled along for the assignment who has had no combat exposure. Both soldiers develop PTSD.

“When they file their claim with the VA, both veterans must prove, and do prove that they have the present condition of PTSD, and a doctor has linked that PTSD to that incident,” De Planque described. “Now they must prove the third element of the claim. They must prove that the incident occurred. The infantrymen has a CIB. As long as his story is consistent with the hardships of combat, his claim [is given the benefit of the doubt and accepted]. The second veteran has no combat decoration. He did his job. He was fortunate enough not to be injured. His story is the same story, but he lacks a decoration that says he was in combat.”

That veteran must now prove several things. First he must prove he was on the convoy, which can be difficult if not impossible, as temporary details are common. Then he must prove the incident occurred. And if reports exist, and actually list all personnel in the convoy, they might not mention the incident of the killed Afghan family, as no Americans were injured and no vehicles were damaged. “If this incident can’t be confirmed in writing, VA must deny the claim,” De Planque declared.

This problem with paperwork impacts members of the National Guard and Reserves—those to whom VA has been especially trying to reach with their PTSD awareness efforts—even harder. Reserve and Guard units sometimes keep separate records, making it particularly hard for those soldiers to piece together their evidence.

On Which Side to Err

Discussion at the hearing turned to the topic of malingering, and whether lowering the evidentiary bar for proving PTSD service-connection would result in an increase in the number of veterans faking the condition in order to receive care or benefits from VA. According to VA, from FY 1999 through FY 2008, the number of patients receiving benefits for service-connected PTSD rose from 120,000 to 345,520.

Dean Kilpatrick, Ph.D., member of the Institute of Medicine’s committee on veterans’ compensation for post-traumatic stress disorder, told the committee that, while there is a need for a reliable, valid way to detect malingering, experts agree that there is no gold standard for doing so. However, he said, the chance of a patient with PTSD being turned away from care is far more likely than one faking the condition to receive care and benefits, and that astute and compassionate physicians should be able to reduce the chance of an error.

“I do think that, by looking at how the symptoms hang together, and the types of experiences, including things that many people don’t know about, and wouldn’t know to think of in order to make something up, we can tell pretty much whether people are telling the truth,” Dr. Kilpatrick said.

He added, “It’s really the stance of people doing these examinations that’s important. If the stance is that we are going to assume that everybody is lying until they prove to me they’re not, we really feel that’s unfair, and unsupported by the data on how much malingering there really is. You can be somewhat skeptical, but say at the same time that I’m going to assume that these people are telling the truth until my antennae go up.”

Rear Admiral David Smith, M.D., USN, joint staff surgeon and chief advisor to the Chairman of the Joint Chiefs of Staff, did not offer an opinion either way on whether the definition of combat needed to be changed, but he did admit that the way DoD and VA work to assess and prove service-connection for disabilities is in dire need of improvement.

“We believe the disability and compensation system requires a revolutionary and systematic overhaul. We’re working closely with VA counterparts to begin this process,” Dr. Smith declared. “We’re keenly aware of the problem, and sometime in the future DoD and VA may ask for assistance from the legislative branch.”

In the meantime, Rep. Hall is erring on the side of easing evidentiary requirements. He has submitted H.R. 952, the “Combat PTSD Act,” for consideration before the VA committee. It would clarify the meaning of combat with the enemy for purposes of service-connection by defining it as active duty in a theater of combat operations during a period of war or in combat against a hostile force during a period of hostilities. “The current policy violates common sense,” stated Rep. Hall following the bill’s submission. “A soldier who does not have PTSD before entering a war, who returns home from war with PTSD, should not have to prove that his PTSD is a result of a specific experience during war. The wars America is fighting right now have no front or rear lines. Danger can strike in any place, anywhere. It is clear that the current regulations are in need of change.”